医保药品目录“双轨制”调整在即 商业健康保险发挥补位价值

Core Viewpoint - The National Healthcare Security Administration (NHSA) has introduced a dual-track system for drug listings, which includes a new commercial health insurance innovative drug directory, highlighting the critical role of commercial health insurance in the medical security system [1][2]. Group 1: Drug Directory Dual-Track System - The new dual-track system allows for basic medical insurance to focus on essential coverage while the commercial health insurance innovative drug directory provides supplementary coverage for high-priced drugs that do not qualify for the basic insurance directory [2]. - A total of 534 drugs were approved for the basic medical insurance directory, while 121 drugs made it to the commercial health insurance innovative drug directory, with a significant majority being Western medicines [2][3]. - Approximately 80 drugs applied for both directories, accounting for about 60% of the commercial health insurance innovative drug directory, indicating a strategic approach to drug approval [2]. Group 2: Role of Commercial Health Insurance - Commercial health insurance is positioned as a "second payment layer" to address the challenges of high-cost innovative drugs and to enhance the multi-tiered medical security system [4][5]. - The increasing demand for innovative drugs due to aging populations and rising medical costs necessitates the involvement of commercial health insurance to cover expenses beyond the basic insurance scope [4][5]. - Local governments are actively promoting commercial health insurance to support the development of innovative drugs, with measures to encourage the integration of innovative drug costs into group health insurance products [6]. Group 3: Challenges and Opportunities - Despite the potential of commercial health insurance, its current contribution to innovative drug payments remains low, with only 7.7% of the market share, indicating a heavy financial burden on patients [7]. - To enhance the payment capacity of commercial health insurance, collaboration among insurance companies, pharmaceutical firms, and healthcare providers is essential, focusing on innovative service models [7]. - The NHSA has introduced supportive policies for the commercial health insurance innovative drug directory, which may help expand coverage and optimize services for high-cost drugs [7][8].